20 CFR CHAPT I PART 10 --CLAIMS FOR COMPENSATION
UNDER THE FEDERAL EMPLOYEES'
COMPENSATION ACT, AS AMENDED (Current through March 1999)
Subpart A--General Provisions
Definitions and Forms
Sec. 10.5 What definitions apply to these regulations?
(x) Recurrence of disability means an inability to work after an employee has returned to
work, caused by a spontaneous change in a medical condition which had resulted from a
previous injury or illness without an intervening injury or new exposure to the work
environment that caused the illness. This term also means an
inability to work that takes place when a light-duty assignment made specifically to
accommodate an employee's physical limitations due to his or her work- related injury or
illness is withdrawn (except when such withdrawal occurs for reasons of misconduct,
non-performance of job duties or a reduction-in-force), or when the physical requirements
of such an assignment are altered so that they exceed his or her established physical
limitations.(y)
Recurrence of medical condition means a documented need for further medical treatment
after release from treatment for the accepted condition or injury when there is no
accompanying work stoppage. Continuous treatment for the original condition or
injury is not considered a ``need for further medical treatment after release from
treatment,'' nor is an examination without treatment.
From PM
PART 2 - CLAIMS\2-1500 RECURRENCES
2-1500-3 Definitions
3.Definitions. The purpose of this paragraph to define recurrences for medical care and
recurrences of disability.
a. Recurrence of Medical Condition. This term is defined as the
documented need for further medical treatment after release from treatment for the
accepted condition when there is no work stoppage. Continued treatment for the original
condition is not considered a renewed need for medical care, nor is examination without
treatment.
b.Recurrence of Disability. This term includes
certain kinds of work stoppages which occur after an employee has returned to work after a
period of disability.
(1) It includes a work stoppage caused by:
(a) A spontaneous
material change, demonstrated by objective findings, in the medical condition which
resulted from a previous injury or occupational illness without an intervening injury or
new exposure to factors causing the original illness;
(b) A return or increase of
disability due to an accepted consequential injury; or
(c)
Withdrawal of a light duty assignment made specifically to accommodate the claimant's
condition due to the work-related injury. This withdrawal must have occurred for reasons
other than misconduct or non-performance of job duties.
(2) It does not include a
work stoppage caused by the following factors (see FECA PM 2-0814.12 concerning these
situations):
(a) Termination of a
temporary appointment, if the claimant was a temporary employee at the time of the injury;
(b) Cessation of special
funding for a particular position or project (e.g., "pipeline" grants);
(c) True reductions in force (RIFs), where
employees performing full duty as well as those performing light duty are affected;
(d) Closure of a base or
other facility; or
(e) A condition which
results from a new injury, even if it involves the same part of the body previously
injured, or by renewed exposure to the causative agent of a previously suffered
occupational disease. If a new work-related injury or exposure occurs, Form CA-1 or CA-2
should be completed accordingly.
However, in some occupational disease cases where the diagnosis remains the same but
disability increases, the claimant may submit Form CA-2a rather than filing a new claim.
For instance, a claimant with carpal tunnel syndrome who has returned to work, but whose
repetitive work activities result in the need for surgery, need not be required to file a
new claim. However, in emotional stress cases a new claim should always be required.
2-1500-4 Claims for Recurrence
4.Claims for Recurrence. The purpose of this paragraph is to discuss how authorization for
further medical care or additional compensation is requested. Such
requests may be received on Form CA-2a or by letter.
a. Evaluating the Request. If a formal decision addressing continuing
injury-related disability for work has been issued, the claimant may be requesting
reconsideration rather than claiming a recurrence. A reconsideration request should refer
explicitly to a prior formal decision and ask that the decision be reevaluated, while a
request to reopen the case should address some material change in the employee's medical
condition or employment status. Requests are sometimes unclear, however, and it is
possible to have a valid claim for recurrence in a denied case if the denial was limited
to a specific period of time or particular medical services, and the claim for recurrence
addresses a different time period or a change in job duties.
b. Advising the Claimant. An employee who
requests action from OWCP based on renewed disability for work or documented need for
medical care should be asked to complete Form CA-2a, Notice of Employee's Recurrence and
Claim for Continuation of Pay. The form should be filled out as follows:
(1) A claimant who is still Federally employed
should complete Part A and give the form to the employing agency for completion of Part B.
(2) claimant who is no longer Federally
employed should complete Parts A and C. The form need not be forwarded to the former
employing agency for completion of Part B.
c. Determining Whether a Decision is Necessary. Claims for recurrence
require adjudication except when:
(1) The claimant is still receiving
continuation of pay (COP). Claims for recurrence of disability for work during this time
almost always occur within 90 days of return to duty, and thus are considered causally
related to the initial injury, as long as no intervening injury occurred. (See paragraph 5
below.)
(2) The recurrence is for medical care only and
the claim is still in open status.
(3) Neither wage-loss compensation nor payment
for medical expenses is claimed at present.
In these instances, the CE should file down the form and remove the disability tracking
record from the automated system. The CE should note on the form or in a short memo to
file why no action is being taken.
d. Advising the Employing Agency. Whether or not the employee is still
employed by the Federal agency for which he or she worked at the time of injury, or is
carried on its rolls, the Claims Examiner (CE) must provide the agency with copies of any
correspondence about a claim for recurrence.
e. Authorizing Benefits. Generally, neither medical treatment nor
compensation should be authorized unless the record contains Form CA-2a with supporting
information. The CE may authorize an emergency medical examination, however, without
waiting for a Form CA-2a.
2-1500-5 Recurrence of Medical Condition
5. Recurrence of Medical Condition. The purpose of this paragraph is to address the
evidence needed to adjudicate claims for recurrent medical care.
a.Within 90 Days of Release from Medical Care (as stated by the
physician or computed from the date of last examination or the physician's instruction to
return PRN). The CE may accept the attending physician's statement supporting causal
relationship between the claimant's current condition and the accepted condition, even if
the statement contains no rationale, unless:
(1) Clear evidence of an intervening injury
appears in the file, in which case factual bridging information should be requested if the
necessary information was not submitted with Form CA-2a. (See FECA Program Memorandum 203
for a definition of an intervening injury);
(2) An intervening decision, such as denial of
continuing disability on the basis of a referee or second opinion specialist's report
which constitutes the weight of medical evidence, has negated this relationship; or
(3) The case was originally accepted for
temporary aggravation of a pre-existing condition. In this instance, reasoned opinion
supporting causal relationship to the work injury should be required.
(4) The renewed claim involves a different
diagnosis from the accepted condition.
b. After 90 Days of Release from Medical Care (again, as stated by the
physician or computed from the date of last examination or the physician's instruction to
return PRN). The claimant is responsible for submitting an attending physician's report
which contains a description of the objective findings and supports causal relationship
between the claimant's current condition and the accepted condition.
(1) The medical evidence needed to establish
causal relationship is outlined in FECA PM 2-805. It should be as conclusive as the
evidence required to establish the original claim.
(2) The CE must evaluate the medical evidence
in terms of any intervening injuries or newly acquired medical conditions as described on
Form CA-2a. If the information provided with Form CA-2a is not sufficient to obtain a
clear picture of the employee's activities and health during the period since release from
medical care, the CE should request clarification or additional information as indicated.
(3) As with recurrences of medical conditions
within 90 days of release from care, additional medical
support for the claim will be needed if an adjudicatory action has negated the original
finding of causal
relationship, or the original acceptance involved a temporary aggravation of a
pre-existing condition.
2-1500-6 Recurrent Disability for Work Within 90 Days of Return to Duty
6. Recurrent Disability for Work Within 90 Days of Return to Duty. The purpose of this
paragraph is to describe the evidence needed to adjudicate claims for recurrence of
disability for work filed shortly after return to light or full duty. Recurrences claimed due to withdrawal of light duty are addressed in
paragraph 7a below.
a. Burden of Proof. The claimant is not required to produce the same
evidence as for a recurrence claimed long after apparent recovery and return to work.
Therefore, in cases where recurring disability for work is claimed within 90 days or less
from the first return to duty, the focus is on disability rather than causal relationship.
b. Disability for Work. Assuming that
requirements described in paragraph 5 above concerning causal relationship are met, the CE
should ask the employee to submit a Form OWCP-5 and/or a narrative statement from the
attending physician which describes the duties which the employee cannot perform and the
demonstrated objective medical findings that form the basis for renewed disability for
work. The CE should obtain a copy of the employee's current position description if it is
not already in file and consider assignment of a Field Nurse to the case.
c. Case Management. The CE should consider a second opinion referral
when a recurrence of disability is accepted if the claimant is not under the care of a
specialist, or if the claimant had previously been released from treatment and disability
for work was not expected to recur, or if a previous history of non-work-related disabling
medical condition exists and the injury was a relatively minor one. In such cases, the CE
should ask the second opinion specialist to address the questions of continuing causal
relationship and whether any residuals exist which prevent return to light or full duty.
2-1500-7 Recurrent Disability for Work After 90 Days of Return
to Duty
7. Recurrent Disability for Work After 90 Days from Return to Duty. The purpose of this
paragraph is to address the evidence needed to adjudicate a claim for recurrence of
disability for work for periods after 90 days from return to duty. This evidence differs
according to whether the claimant returned to light or full duty. It
does not matter whether the case is open or closed.
a. Claimants Performing Light Duty. The
reason for claiming the recurrence may be medical, or it may
stem from withdrawal of a light duty assignment or other issue affecting the suitability
of the work performed. The claimant's work limitations may be well established and stable,
or they may be changing in the recovery process.
(1) Burden of Proof. Claimants who are
performing light duty are not considered fully recovered from their work-related injuries.
This is true whether or not they have been rated for LWEC. Therefore, the claimant's
burden of proof is mainly to establish that any increase in disability for work is due to
the accepted injury, rather than another cause (see Terry L. Hedman, 38 ECAB 222).
However, an increase in pain does not constitute objective evidence of disability (see
Sally S. Weinacht, Docket No. 91-1035, issued November 12, 1991).
(2) Medical Issues. The CE should obtain
a Form OWCP-5 and a narrative statement from the attending physician which describes the
duties which the employee cannot perform and the demonstrated objective medical findings
that form the basis of renewed disability for work. This information should be evaluated
in light of any intervening injuries or subsequently acquired medical conditions reported
on Form CA-2a. The CE should obtain a copy of the employee's current position description
if it is not already in file.
(3) Suitability
Issues. If the claim for recurrence of disability for work is based on modification of the
claimant's duties, or on the physical requirements of the job, the claimant should be
asked to describe such changes, and the employing agency should be asked to comment.
(4) Withdrawal of
Light Duty. If the employing agency has withdrawn a light duty assignment made
specifically to accommodate the claimant's condition due to the work-related injury (i.e.,
a RIF or closure of the facility is not involved), and the withdrawal did not occur for
cause, the CE need only establish continuing injury-related disability for regular duty to
accept the recurrence and begin payment of benefits.
To do so, the CE will need to ensure that the file contains an accurate description of the
nature and extent of injury-related disability. If it does not, the CE will need to obtain
this information from the attending physician and/or second opinion specialist. After
accepting the recurrence, the CE should refer the case for vocational rehabilitation
services.
FECA PM 2-0814.12 addresses situations where employment is
terminated due to a RIF or closure of a facility.
a. ...
b. Claimants Performing Full Duty. Where the employee had
returned to full duty for more than 90 days, substantial evidence must show that the
recurrence of disability for work is directly related to the original injury.
(1) Burden of Proof. It is the employee's
burden to submit factual and medical evidence in support of the claimed recurrence. It is
not assumed that any subsequent incapacity involving the injured part of the body is the
result of the original injury solely because the original injury was accepted.
(a) Factual evidence includes the items requested on Form CA-2a, i.e., a description of
the condition and any changes in duties during the intervening period, and a description
of any intervening injuries and medical treatment for them.
(b)
Medical evidence includes a description of objective findings, reasoned medical opinion
supporting causal relationship, and a discussion of any similar pre-existing or
intervening condition affecting the same part of the body.
(2) Evidence. In addition to the medical
and factual information requested on Form CA-2a, the CE should send Form CA-1027, Request
to Private Employer for Employment History, to confirm the dates of any private
employment, the type of employment, and the reason for its termination.
2-1500-8 Compensation for Recurrent Disability
8. Compensation for Recurrent Disability. The purpose of this paragraph is to describe the
steps needed to pay compensation in a case where a recurrence of disability for work has
been accepted. The employee should submit Form CA-7 to claim compensation. (However, where
a previous claim was paid so recently that information already in file concerning pay
rate, health benefits and life insurance deductions, and dependents can be considered
current, Form CA-8 may be filed instead.) (CA-8 replaced by new
CA-7) The following guidelines should be observed:
a. Use of COP. Where fewer
than 45 days of COP were used, the remaining days may be authorized if less than 90 days
have elapsed since the date of first return to duty.
b. Compensation Factors. The claimant may be entitled to a
recurrent pay rate (see FECA PM 2-900). If the claimant worked for a private employer, the
CE will need to obtain confirmation from the employer of the pay rate reported by the
employee in Part C of Form CA-2a.
c. Certification. The CE and certifier are responsible for
ensuring that the record contains sufficient medical and factual evidence to establish a
causal relationship between the medical condition underlying the recurrent disability for
work and the original accepted condition.
d. Schedule Awards. A schedule award and compensation for
recurrent disability may be paid for the same injury (though not, of course, at the same
time). If the schedule award is being paid in a lump sum, however, compensation is not
payable for the duration of the schedule award, though the date of recurrence may be
established during that time.
This is from FECA Rehab and
Returning to Work, When an offer is refused (Revion VI in Jacksonville, FL):
If the re-employed worker stops work again take one of the following actions (when indicated):
If the work stoppage is due to a new injury, assist the employee
with filing a form CA-1 or
CA-2 where appropriate.
If the work stoppage is due to a recurrence of the work injury,
assist the employee with filing
a form CA-2a
If there is no reason given for the work stoppage, notify OWCP
and request that the office
investigate the stoppage and render a suitability decision if appropriate. |
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